Provider Demographics
NPI:1578033593
Name:DENT, LATOSHA
Entity type:Individual
Prefix:
First Name:LATOSHA
Middle Name:
Last Name:DENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 W BURBANK BLVD # 5300
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-1315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1812 W BURBANK BLVD # 5300
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-1315
Practice Address - Country:US
Practice Address - Phone:206-430-8118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-03
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60903459363LP0808X
CA95010715363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5966342Medicaid